Facility Evaluation Report

Licensing Program Analyst (LPAs) Deniz and Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Hannah Peralta. All clients were attending day program during visit.

LPAs/Administrator initiated a tour of the facility at 9:30 am and made the following observations: Facility was a comfortable temperature. Resident rooms were furnished per regulation. Water temperature in client bathroom measured at 112.6 and 115.3 degrees F which is within allowable range of 105 to 120 degrees F. During todays visit LPAs have follow up on areas of concern identified by another agency semi-annual review, regarding building and grounds, LPAs observed a drain cover in located bathroom # 1. Also, LPAs reviewed medication records and conducted a spot check of medications did not reveal any discrepancies. Extra hygiene products and linens were available. Cleaning supplies stored under kitchen sink and in garage were inaccessible to residents in care. Knives and other items that could pose a risk were locked. Medications were centrally stored and locked. Fire extinguishers are charged and serviced May 2024. Combination smoke/carbon monoxide alarms were tested and operational at time of inspection. The home is fire sprinkled and has interior fire doors. A generator is used as their second required power source. Most recent fire/disaster drill was completed 1/15/2025. Cash resources were reviewed. Full bed rails and PRN waiver on file. Facility has at least two days of perishable and one week of non-perishable foods. Currently there are clients who are fed through G-tubes. LPAs was able to verify that facility maintains a 7+ day supply of client prescribed nutritional formulas and supplies. LVNs and RNs are responsible for all tube feeds and medications.